Cowper’s Cut: The what, the why and the how

Andy Cowper on how it may be time for a fresh look at the problems facing NHS services and organisations

Commentators make comments, which is all well and good if (like me) you are one, but the commodity value and use value of those comments can feel opaque.

In a system busting a gut to stay upright; to deliver safe, timely and effective care; and to meet rising demand with scarcely-rising resources, perhaps the service wouldn’t see much value in another ”this is just how much of the brown stuff has/will hit the rotating thing” could clearly be pretty marginal.

So I’m not writing one of those.

I’d love to be able to tell you there were some cavalry coming to the rescue, but I think you probably know me well enough to understand that I’m not going to lie to you.

All the cavalry that are not coming

It’s clear that there won’t be any financial cavalry until the bleeding obvious (the need for more of the right kind of staff doing the right sort of roles in functional environments) turns into the obvious bleeding.

The irony of STPs and ACOs being the culprits for privatising the NHS when they are in reality creations to euthanise the competitive internal market shouldn’t be lost on anyone who thinks about things

This government, and in particular “Treasury” – or to give them their full official title, ”the Treasury Munchkins” – are not there yet. They’ll get there, late and using the bypass of other people’s suffering. Tick-tock. Tick-tock. Time will tell: it always does.

The organisational form cavalry probably doesn’t have too many true believers left; at least, not un-bought ones with a working memory. The grotesque mishandling of the communication of sustainability and transformation partnerships (STPs) is starting to happen over accountable care organisations/systems (ACO/S), and so the NHS privatisaition narrative winds its wearisome, wrong way across the health policy landscape once more. Sigh.

The irony of STPs and ACOs being the culprits for privatising the NHS when they are in reality creations to euthanise the competitive internal market shouldn’t be lost on anyone who thinks about things.

Wanted: an NHS chief anthropologist

It’s not about the structures: it’s about the relationships. This is why I keep banging on about the need for a chief anthropologist far outweighing that for any chief inspector. You’ve got to be able to understand and name tribalism of professions and generations to stand a hope of negotiating some much needed and durable peace treaties.

I’m a little more optimistic about this than I used to be. The brighter leaders in the NHS are getting the concept. There’s a very long way to go, but some people are actually being leaders and taking the first steps. You know who you are: good on each and every one of you.

The what, the why and the how

It may be time for a fresh look at the problems facing NHS services and organisations. The problems aren’t the same everywhere, but there are three broad approaches worth trying.

The first is “the what”: what is the fundamental, underlying reason why we have got this major problem? It’s often the affordability and availability of workforce – but it isn’t always.

There is some rigour required and you clearly need to understand the basic rules of the game and to measure effectively and accurately

Something that’s often a common factor in the NHS management culture in problem organisations is the Red Adair Syndrome. Problems are left and tolerated until they become an enormous burning crisis: one which requires a heroic response, with all hands to the pump and long, long hours. The NHS is far better at this than any well-run system should be.

If your team or organisation has Red Adair Syndrome, it’s not well-led and it’s almost certainly disastrously bad at root cause analysis.

Root cause analysis is our guide to the second stage: the why. (oh and you have to eschew the other classic NHS management Learned Helplessness – that of always defaulting to the money.)

This is about getting to the fundamental issue that has caused the problem. “We can’t recruit or retain nurses and junior doctors.’ ‘Why?’ ‘Because no one wants to work here.’ ‘Why?’

You’re usually getting to the start of the problem by the second why. Keep going. These things are rarely mono-factorial. Some people think that five whys are required.

Lastly, we get ourselves back to the point where technical operational management skills (which are in desperately short supply) meet the cultural and anthropological need: this is the how.

Specifically, it’s the ”how do we change things so that not only have we implemented a durable solution that colleagues understand, but also ensure that we’ve made enough change that we will not slide back into traditional bad practices that gave rise to the very root problem in the first place?”

”The what, the why and the how” approach is not quantum physics. It’s got much more in common with rocket science: there is some rigour required and you clearly need to understand the basic rules of the game and to measure effectively and accurately.

Thank you for the pleasure of your company this year. I look forward to being seen by you in 2018. Have a Happy Christmas, and best wishes for the new year.

The failings of the Care Quality Commission in applying the fit and proper person test to a disgraced trust chief executive were so severe the Parliamentary health watchdog has fears of “systemic injustice”.